INTERNAL PROCEDURES FOR HANDLING OF CLAIMS AND COMPLAINTS ON INSURANCE CONTRACTS

Transcription

1 Sogelife Bulgaria JSC, 73, Aleksandar Stambolijski blv., Sofia INTERNAL PROCEDURES FOR HANDLING OF CLAIMS AND COMPLAINTS ON INSURANCE CONTRACTS With these rules are defined the procedures for handling of insurance claims, lodged on the basis of concluded Individual and group life insurance contracts with Sogelife Bulgaria (further called Insurer or the Company). The process of handling of a life assurance claim starts on the date of lodging of an insurance claim and lasts to the date of its full and final settlement by the company. I. REGISTRATION OF A CLAIM 1.1 In order to lodge a claim the Claimant must fill in a claim form in a form of the Insurer and to use the appropriate one according to a certain insurance contract. 1.2 Each beneficiary fills in a separate claim form. In cases of more than one claim for the same Claimant, different claim forms must be filled in for each separate claim. 1.3 The claimant can lodge a claim at the headquarters of the Insurer on the following address: 73, Aleksandar Stambolijski blv., Sofia or at any other office of the company by supplying the claim form and all required documents according to section II below. The claimant might lodge a claim as well as to all brokers and agents, which have the right to receive and collect documents on claims on behalf of the Insurer. All the claims forms and required documents must be sent to the Insurer by a registered post. 1.4 The initial notification of a claim might be done by fax, telephone or , but the claimant is obliged to send all the original documents as soon as possible after that. 1.5 The claim might be handled only on the basis of all received original documents by the claimant. 1.6 In cases when the claim is lodged in the headquarters of the Insurer, the claimant must produce an ID card and to sign a claim form in a front of an employee from Claims Department. 1.7 The insurer accepts a notification of a claim by the way of an incoming registration number, including the date of receiving of the claim (it must be the same date as the date of actual receiving of a claim form). 1.8 An employee from Claims Department checks if the claim form was filled in properly and in the cases of submission of a claim at the headquarters asks instantly the claimant to fill in the missing data. 1.9 In cases when the claim form was submitted by post, fax or , the requirement for fulfillment of missing data will be done in writing with a letter with outgoing registration number and by the registered post. II. DOCUMENTS REQUIRED FOR ASSESSEMNT OF VALIDITY AND AMOUNT OF A CLAIM 2.1 Lodging of an insurance claim the claimant is obliged to attach all necessary documents according to the requirements of an insurance agreement or the General Conditions for each type of product. 2.2 In case of death alongside with the claim form the following documents must be presented to the Insurer: - Original insurance policy or original insurance membership certificate in cases of group policy, with which the claimant proves their right to lodge a claim; - All annexes to the original insurance contract if there are any; - The copy-extract of death certificate showing the date of birth;

2 - a photocopy of certificate (notification for death) using the model provided by the Insurer and completed by the doctor certifying death indicating the cause of death, which certificate could be sent to the Insurer s medical adviser in a sealed envelope; - Other documents, proving the date, cause/es and consequences of the insurance event; for the accidental death guarantee, the evidence of the accident as cause of the death; - Any other document that the Insurer may deem necessary as history of the disease, Personal Medical File (LAK), police report, any medical expertises as chemical expertise, and other documents according to art. 105 of the Code of Insurance. - Certificate for heirs if there are no beneficiaries shown in the policy; 2.3 In case of Total and Irreversible Loss of Autonomy (TILA) or Permanent Total Disability (PTD) the documents required by the Insurer are: - Original insurance policy or original insurance membership certificate in cases of group policy, with which the claimant proves their right to lodge a claim; - All annexes to the original insurance contract; - A medical certificate addressed in a sealed envelope to the Insurer s medical adviser using the model provided by the Insurer, completed by the doctor providing treatment and which shows the nature of the injuries or illness, the resultant permanent impairment and the date of consolidation TELK/NELK decision if available; - For the PTDA guarantee, the evidence of the accident as cause of the PTD state; - For the PTD or PTDA guarantees, the evidence that the insured person was carrying an officially registered occupation both on the date of his application for membership and on the commencement of his/her total disability; - In cases of accident - data about the circumstances of occurrence of the accident (place and date of the accident, full description of the accident); name of a doctor, performed medical examination after the accident and who defined or performed necessary medical treatment; conclusion of the doctor about the nature and the degree of physical injuries as well as eventual consequences, information about pre-existing conditions and illnesses, injuries existing before the date of the accident; existing medical documents about definitely found medical conditions with the aim of defining the final percentage of disability - Any other document that the Insurer may deem necessary according to art. 105 of the Insurance Code 2.4 In case of Temporary Disability the documents required by the Insurer are: - Original insurance policy or original insurance membership certificate in cases of group policy, with which the claimant proves their right to lodge a claim; - All annexes to the original insurance contract; - Sick leave certificates; - Any other documents that the Insurer may deem necessary according to art. 105 of the Insurance Code; 2.5 In case of survival on the end date of the insurance contract: - Evidence of having right to claim the payment if not evident from the policy /certificate for heirs if they are beneficiaries but are not named in the policy/; - the ID card of the life assured or declaration sighed in a front of a notary by the insured that they are alive on the end date of the insurance contract, if the life assured does not appear personally to receive the sum assured. 2.6 If the original insurance policy or original insurance membership certificate is missing or lost this is not a reason for a refusal of the claim. 2.7 If the claimant needs the original documents back, the employee from Claims Department must make copies, to certify them with a stamp Identical with the original, to put their signature and to return back the originals to the claimant. III. COLLECTION OF PROOF FOR ASSESSEMNT OF VALIDITY AND AMOUNT OF A CLAIM 3.1 An employee from Claims Department opens an individual file for each separate claim and for each separate beneficiary, including the following information: 2 Procedures for handling of claims and complaints of Sogelife

3 - Consecutive number of the claim (unique individual number) and the date of registration of the claim. The employee gives this data to the claimant in order to allow them to have the reference number in their further communication; - If at lodging of a claim not all required documents are attached, an employee handling the case must inform the claimant in written asking for missing documents and explaining that they should be received in the company as soon as possible as it is not possible to handle the claim without them. 3.2 Additional evidence might be asked only in cases of necessity and subject to the fact that the necessity could not been foreseen on the date of lodging of the claim and not later than 45 days from the date of presenting of the evidence, required at lodging the claim and listed in the insurance contract and these rules. 3.3 The final term for lodging of a claim is 5 years from the occurrence of an insurance event. 3.4 All the costs for collection of information and documents for proof of validity and amount of a claim are for the claimant themselves. 3.5 The insurer has the right of access to any medical data at appropriate institutions, which have it at their disposal as hospitals, medical establishments and any other medical institutions, for which an insured person gave their consent on an application form and subject to strict observation of Data Protection Act. 3.6 The insurer cannot ask for information or documents which the insured person cannot obtain because of some existing normative drawbacks or lack of legal way to obtain them as well as such evidence which is not relevant for the assessment of the claim and aims unreasonable delay of its handling. IV. ASSESSEMNT OF THE DEGREE OF A CLAIM 4.1 The insurer prepares the basis for assessment of the claim, grounds and procedures for defining of the payment on the basis of collected required document as shown above. 4.2 Claims Department assesses medical consequences as a result of occurred insurance event on the basis of received medical documents. In cases of assessment of Permanent Total Disability or Total and Irreversible Loss of Autonomy (TILA) the degree of disability is assesses by a doctor appointed by the Insurer. Sogelife Bulgaria reserves the right to cause the Insured s state of health to be verified by any authorized person designated by it. From that time payments shall be suspended until the medical report is received by the Consulting Physician of Sogelife Bulgaria. The state of PTD is determined by a doctor designated (appointed) by the Insurer based on received medical documents, including TELK/NELK decision in 15 days from receiving of all required documents. 4.3 The Insurer is not bound by any opinions (even those from the official bodies authorized to give such opinion according to the compulsory Social Security Code). 4.4 In cases when the disability claim notification is delayed with more than 4 months and unless the Insured can prove he/she was unable to make the notification of a claim, then the Insurer reserves the right, in view of the prejudice caused by the inability to verify the degree of disability, to set the day of disability at the date of declaration to the Insurer. 4.5 Any retention of information or intentionally false declaration on the part of the claimant or the production of inexact or falsified documents purporting to show the date, circumstances or consequences of the loss will result in forfeiture of any cover for the claim in question. 4.6 At a proposal of the doctor appointed by the company, the life insured might be called for a medical examination. A notification for a medical examination must be sent showing the place and date of examination. On the basis of conducted medical examination and according to the wordings of a certain type of product, the doctor appointed proposes in written a percentage of lost ability to work. 3 Procedures for handling of claims and complaints of Sogelife

4 4.8 Any doctor authorised by the Insurer must be able to have access to the Insured suffering from disability, at any time on any working day up till 8pm at the place where he/she is undergoing treatment or at his/her home so as to be able to check on the seriousness of his/her state of health, failing which insurance cover may be denied. V. DEFINITION OF THE AMOUNT OF INSURANCE PAYMENT The amount of insurance payment depends on the definitions and procedures as specified in the insurance contract or General Condition by type of product and per type of risk covered. 5.1 In case of an insurable event a sum insured will be paid as it was defined at the inception of insurance cover. It might be a lump sum or part of it. In the latter case the partial payment is based on the percentage of defined disability by the Insurer s appointed doctor. 5.2 Insurance payment might depend on the cause of death sickness or accident according to the insurance contract (there might be double payment in case of accident). 5.3 The Insurer has the right to subtract all non-paid premiums form the insurance payment as well as any taxes or legal obligations that the Insurer is obliged to subtract by law. VI. INSURANCE PAYMENT 6.1 The Insurer will take one of the following decisions in 15-days form receiving of all necessary documents required as per part II or additionally required by the Insurer: - to accept a claim as a valid one - to refuse to pay a claim 6.2 All insurance payment must be done in 15-days period form receiving of all necessary documents on a bank account of the beneficiary/ies shown in the claim form. 6.3 The insurer is obliged to send a written notification to the claimant with a registered post showing the amount of insurance payment, ground for payment (death, disability etc.) as well as subtracted amounts, if any. The notification for payment must indicate if the insurance payment is a lump sum and if this terminates the insurance cover. 6.4 The claim is payable in the original currency of the risk (the currency of sum insured and premiums payable) unless the insured person wishes to receive the payment in BGN. In this case the exchange rate will be the official exchange rate of National Central Bank on date of payment. 6.5 In cases where the Insurer on the basis of the documents and information supplied decides that the claim is unjustified and therefore no insurance payment will be done, they inform the claimant in written. Notification about refusal concludes all data for identification of a claim (number of the claim, date of occurrence of the insured event etc.) as well as the reason for refusal of payment. VII. PROCEDURE FOR HANDLING OF COMPLAINTS 7.1 All the compaliants must be submitted at the headquarters of the Insurer at 73, Alexandar Stambolijsku blv., Sofia. 7.2 Complaint must be written in a plain language and contain the following minimum information: the name of the claimant, address of the person as well as telephone number for contacting them, reasons for the complaint, signature of the claimant and date of submission of the complaint. 7.3 If there is a difference in the opinions between the Insurer and the Insured (or the Insured s next of kin in the event of death) then amicable or judicial means will be used to bring in a medical expert with the capacity to act as arbitrator between the two different viewpoints. 4 Procedures for handling of claims and complaints of Sogelife

5 7.4 The costs and fees incurred for the first two medical experts are borne by the party which appointed the expert, those incurred for a third expert as well as for their designation are split fifty/fifty between the Insurer and the Life Insured. 7.5 All decisions of the insurer taken on the basis of the conclusions of the appointed doctor will be notified to the insured by registered letter and are binding on the insured if he/she has not challenged them within two months of their notification by providing a detailed medical certificate. Any such objections must be addressed to the insured by a registered letter. 7.6 The procedure for handling of complaints must be quick, objective as well as it is necessary to comply with legal requirements, insurance practice and the rights of the claimants. 7.7 The procedure for reviewing of complaints will end up with issuing of a decision in a form of a written answer showing the grounds for the decision taken not later than 30 days from receiving of the complaint. The answer must include the legal basis for the decision as well as the legal rights of the claimant if they are not satisfied by the decision. The possibilities outlined must include the option for an out-of-court settlement of a dispute in the first place, including hiring of independent parties as experts. VIII. CONFIDENTIALITY 8.1 The data in a claim form and attached medical documents will be treated with strict confidentiality. A claims handler (employee of Claims Department), who handles the claim as well as all the other employees, who have access to that information, observe the rules for confidentiality and internal rules of the Company with the aim of prevention of use of those information by unauthorized persons during the period of claims handling as well as after its closing. The persons, who have access to the documents, related to the insurance claim are policyholder, life assured, beneficiaries, legal heirs of the policyholder/life assured or other legally authorized person or a person, who has access to the information in question by operation of law. 8.2 Information might be given to persons who have legal right of access to the information only on the basis of their written request and submission of a document proving their legal right to have access to it. 8.3 Employees can give the original documents to competent government bodies in case when the original documents are necessary in the process of conducting an investigation. In these cases Claims Department gives all original documents and makes photocopies, which remain in the Company. Alongside with the copies be prepared a report, which shows the location of original documents. Giving of the original documents is performed by a written statement signed by the both parties. All documents which are copies and which Claims Department uses in the process of handling of claims be marked with a stamp True with the original and this be certified with a signature. ІX. FINAL PROVISIONS These Rules have been accepted according to art.104, par. 1 of the Code of Insurance. These Rules were accepted with the decision of the Board of Directors of, which is mentioned in the Minutes No 05 dated and amended with the decision of the Board of Directors held on , mentioned in Minutes N 06 dated Procedures for handling of claims and complaints of Sogelife